New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 56 - MANUAL FOR DENTAL SERVICES
Subchapter 3 - HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS)
Section 10:56-3.2 - D0100-D0999 DIAGNOSTIC

Universal Citation: NJ Admin Code 10:56-3.2

Current through Register Vol. 56, No. 18, September 16, 2024

(a) Clinical Oral Examination:

Maximum Fee
HCPCSAllowance
INDCodeModProcedure DescriptionS$NS
D0150Comprehensive oral evaluation15.0014.00

NOTE 1: This code is to be used for comprehensive clinical oral evaluation of a Medicaid/NJ FamilyCare fee-for-service beneficiary.

NOTE 2: This code requires a thorough observation of all conditions present in the oral cavity and contiguous structures to include:

a. An oral cancer screening;

b. Charting of all abnormalities;

c. Development of a complete treatment plan to be recorded in its entirety, including provisions for further treatment and follow-up, by referral if necessary;

NOTE 3: For reimbursement of the comprehensive oral evaluation with code D0150:

a. The examination is limited to once every six months for patients under 21 years of age and every 12 months for patients over 21 years of age, except as authorized by a dental consultant of the New Jersey Medicaid/NJ FamilyCare program;

b. All items on the Dental Services Claim form (MC-10) should be completed;

c. If no other treatment is necessary, this fact must be noted on the Dental Services Claim form (MC-10) in the diagnosis box (20). The abbreviation "NOTN" may be used to indicate no other treatment needed.

D015076Comprehensive oral evaluation14.0013.00

NOTE 1: This code is to be used only if a beneficiary is developmentally disabled or neurologically impaired (see 10:56-2.9(a)1 ii), in which case an examination may be provided as often as every three months and may be submitted directly to the fiscal agent for payment without prior authorization. The nature of the beneficiary's disability must be recorded under "Remarks" on the Dental Services Claim form (MC-10).

D0150EPComprehensive oral evaluation25.0021.00

NOTE 1:

a.This code is to be used for comprehensive oral evaluation of a Medicaid/NJ FamilyCare fee-for-service beneficiary through and including the age of 20.

b. This code is to be used for comprehensive oral evaluation referred from EPSDT screenings.

NOTE 2: This code requires a thorough observation of all conditions present in the oral cavity and contiguous structures to include:

a. An oral cancer screening;

b. Assessment of dental development;

c. Charting of all abnormalities;

d. Development of a complete treatment plan to be recorded in its entirety, including provisions for further treatment and follow-up, by referral if necessary;

e. Anticipatory guidance concerning dental health to the patient or parent/guardian;

f. Assessment of the caries index and nutritional needs relating to oral health and oral hygiene practices;

g. Assessment of systemic or topical fluoride needs.

NOTE 3: For reimbursement of the comprehensive oral evaluation with code D0150 EP:

a. The examination is limited to once every six months for patients under 21 years of age, except as authorized by a dental consultant of the New Jersey Medicaid/NJ FamilyCare program;

b. All items on the Dental Services Claim form (MC-10) should be completed;

c. If no other treatment is necessary, this fact must be noted on the Dental Services Claim form (MC-10) in the diagnosis box (20). The abbreviation "NOTN" may be used to indicate no other treatment needed.

D0120Periodic Oral Evaluation15.0014.00

NOTE: An evaluation performed on a patient of record to determine any changes in the patient's oral health status since a previous initial or periodic examination.

D0120EPPeriodic Oral Evaluation15.0014.00

NOTE: This code is to be used with an EPSDT referral on a patient of record to determine any changes in the patient's oral health status since a previous initial or periodic examination.

dD0140Limited oral evaluation4.003.00

NOTE: Make note of diagnosis and/or observation(s) on the Dental Services Claim form (MC-10).

D0160Detailed and extensive oral14.0013.00
evaluation problem focused by
report.
D0170Re-evaluation--limited, problem14.0013.00
focused (Established patient; not
post-operative visit)

(b) Radiographs:

1. Intraoral Radiographs: (Periapicals/Bitewing/Occlusal)
i. Indicate number of films in item 13 of the Dental Services Claim form (MC-10);

ii. For a complete series of radiographs, limitations pertaining to age are found in the first note below each code, and the maximum number of radiographs reimbursable as a single radiographic study every three years without prior authorization is found in the second note below each code.

Maximum Fee
HCPCSAllowance
INDCodeModProcedure DescriptionS$NS
D021052Intraoral-Complete Series18.0018.00

NOTE 1: Limited to patients up to and including age six.

NOTE 2: Eight films.

D0210Intraoral--Complete Series22.0022.00
(including bitewings)

NOTE 1: Limited to patients age seven up to and including age 14.

NOTE 2: Twelve films.

D021022Intraoral--Complete Series26.0026.00
(including bitewings)

NOTE 1: Limited to patients age 15 or older.

NOTE 2: Minimum of 16 films.

D0220Intraoral--Periapical--First Film3.753.75
D0230Intraoral--Periapical--Each2.752.75
Additional Film

NOTE 1: Indicate complete number of films (D0220 Plus D0230) in item 13.

D0240Intraoral--Occlusal Film5.005.00

NOTE 1: Per film (maximum--two films).

NOTE 2: Indicate number of films in item 13.

2. Extraoral Radiographs

D0250Extraoral, First Film10.0010.00

NOTE: Code to be used for lateral, anteroposterior, temporo-mandibular radiographs, etc. (one view).

D0260Extraoral--5.005.00
Each Additi
onal Film

NOTE 1: Indicate number of views in item 13.

NOTE 2: Maximum reimbursable--two additional views.

D0270Bitewing--Single film3.003.00
D0272Bitewings--Two films5.005.00
D0274Bitewings--Four films9.009.00
D0290Posterior--anterior or lateral10.0010.00
skull and facial bone survey film
D0310Sialography15.0015.00
D031022Sialography30.0030.00

NOTE: Includes injection of contrast material (filling and/or emptying phases).

D0320Temporomandibular joint30.0030.00
anthrogram, including injection
D0321Other temporomandibular jointBRBR
films, by report
D0322Tomographic survey125.0090.00
D0330Panoramic Film15.7515.75
D0340Cephalometric Film15.0015.00
D034022Cephalometric Film22.5022.50

NOTE: Includes tracing.

(c) Test and laboratory examinations:

D0470Diagnostic Casts11.5010.00

NOTE 1: Casts must have bases and be trimmed to permit articulation, per cast.

NOTE 2: Code not to be used in conjunction with denture construction.

D0472Accession of tissue, gross9.359.35
examination, preparation and
transmission of written report
D0473Accession of tissue, gross and20.8520.85
microscopic examination,
preparation and transmission of
written report
D0474Accession of tissue, gross and40.0040.00
microscopic examination, including
assessment of surgical margins for
presence of disease, preparation
and transmission of written report
D0480Processing and interpretation of12.0012.00
cytologic smears, including the
preparation and transmission of
written report
D0350Oral/facial images (includes intra1.001.00
and extraoral images)

NOTE: Or slides, per view.

dD0501Histopathologic Examination10.0010.00

NOTE 1: The gross and microscopic examination of oral tissues, both hard and soft.

NOTE 2: Limited to specialists in oral pathology, and Oral Diagnosis (Pathology) Departments of dental schools.

D0502Other oral pathology procedures,BRBR
by report
d*D0999Unspecified Diagnostic Procedure,BRBR
By Report

NOTE: Complete description of procedure and the reason the procedure was performed.

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